Meta-Analysis of Oral Anticoagulant Monotherapy as an Antithrombotic Strategy in Patients With Stable Coronary Artery Disease and Nonvalvular Atrial Fibrillation

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Highlights

  • Evidence for optimal antithrombotic regimen for AF with stable CAD is limited.

  • This meta-analysis compared outcomes between OAC monotherapy and OAC plus SAPT.

  • OAC monotherapy showed similar efficacy but significantly lower risk of bleeding.

  • Further evidence regarding DOAC in AF patients with stable CAD is required.

Guidelines recommend oral anticoagulant (OAC) monotherapy without antiplatelet therapy (APT) in patients with nonvalvular atrial fibrillation (AF) with stable coronary artery disease (CAD) of >1 year after myocardial infarction or percutaneous coronary intervention. More evidences are required for the safety and efficacy of OAC monotherapy compared with OAC plus APT. PubMed, EMBASE, and Cochrane Database of Systematic Reviews were systematically searched up to February 2019. Nonrandomized studies and randomized clinical trials comparing OAC monotherapy with OAC plus single APT (SAPT) for patients with stable CAD and nonvalvular AF. The primary end point was major adverse cardiovascular events (composite of ischemic or thrombotic events) and secondary outcomes included major bleeding, stroke, all-cause death, and net adverse events (composite of ischemic, thrombotic, or bleeding events). From 6 trials, 8,855 patients were included. There was no significant difference in major adverse cardiovascular event in patients with AF treated using OAC plus SAPT compared with those treated with OAC monotherapy (hazard ratio [HR] 1.09; 95% confidence interval [CI] 0.92 to 1.29). OAC plus SAPT was associated with a significantly higher risk of major bleeding compared with OAC monotherapy (HR 1.61; 95% CI 1.38 to 1.87), as well as in terms of net adverse event (HR 1.21; 95% CI 1.02 to 1.43). There were no significant differences in rates of stroke and all-cause death. In conclusion, in this meta-analysis, OAC monotherapy and OAC plus SAPT treatment showed similar effectiveness, but OAC monotherapy was significantly associated with a lower risk of bleeding compared with OAC plus SAPT in patients with nonvalvular AF and stable CAD.

Section snippets

Methods

We performed electronic searches of PubMed, EMBASE, and the Cochrane Database of Systematic Reviews to identify studies that included specific keywords relevant to this topic. We added manual search results, including references cited in electronically searched articles, recent reviews, editorials, and meta-analyses. We did not apply any restrictions regarding the language, study period, or sample size. A description of the detailed study methods including search strategy is included in the

Results

Figure 1 presents an overview of the search and selection process used in this meta-analysis. A total of 8,855 patients with stable CAD and nonvalvular AF were included in the 6 studies. A summary of important study characteristics can be found in Table 1 and eTable 4 in the online supplement. Only recent publications included direct oral anticoagulant (DOAC) users (27%, 40.6%, and 24.8% of total study population).9, 10, 11 Patients with DOAC accounted for 8.6% of total of 8,855 pooled

Discussion

Our principal findings are as follows: (1) the pooled HR for major bleeding and NAE were significantly higher in the OAC plus SAPT group, whereas there were no significant differences in MACE, stroke, and death; (2) in general, consistent findings were observed in various subgroup analyses, including BMS and DES studies; (3) OAC monotherapy showed more benefit for MACE in the subgroup with higher proportion of previous MI patients; (4) in the studies after the introduction of DOACs, OAC

Disclosures

SRL, TMR, DYK: none; EKC: research grant from Daiichi-Sankyo, BMS/Pfizer, and Biosense Webster; SO: research grant from Bayer Korea, BMS Korea, Boehringer-Ingelheim Korea, Daiichi Sankyo Korea, Pfizer Korea. No fees are received personally; GYHL: consultant for Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon and Daiichi-Sankyo. Speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi-Sankyo. No fees are received personally.

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  • Cited by (0)

    Funding: None.

    1

    Drs. Lee and Rhee contributed equally to this work and are joint first authors.

    2

    Drs. Oh and Lip contributed equally to this work and are joint senior authors.

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